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Committee on the Assessment of Ongoing Efforts in the
Treatment of Posttraumatic Stress Disorder
Board on the Health of Select Populations
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THE NATIONAL ACADEMIES PRESS 500 Fifth Street, N.W. Washington, DC 20001
NOTICE: The project that is the subject of this report was approved by the Govern-
ing Board of the National Research Council, whose members are drawn from the
councils of the National Academy of Sciences, the National Academy of Engineer-
ing, and the Institute of Medicine. The members of the committee responsible for
the report were chosen for their special competences and with regard for appropri-
ate balance.
This study was supported by Contract No. W81XWH-10-C-0290 between the
National Academy of Sciences and the Department of Defense. Any opinions, find-
ings, conclusions, or recommendations expressed in this publication are those of
the author(s) and do not necessarily reflect the view of the organizations or agencies
that provided support for this project.
International Standard Book Number-13: 978-0-309-25421-2
International Standard Book Number-10: 0-309-25421-3
Additional copies of this report are available from the National Academies Press,
500 Fifth Street, NW, Keck 360, Washington, DC 20001; (800) 624-6242 or (202)
334-3313; http://www.nap.edu.
For more information about the Institute of Medicine, visit the IOM home page
at: www.iom.edu.
Copyright 2012 by the National Academy of Sciences. All rights reserved.
Printed in the United States of America
The serpent has been a symbol of long life, healing, and knowledge among almost
all cultures and religions since the beginning of recorded history. The serpent ad-
opted as a logotype by the Institute of Medicine is a relief carving from ancient
Greece, now held by the Staatliche Museen in Berlin.
Suggested citation: IOM (Institute of Medicine). 2012. Treatment for posttraumatic
stress disorder in military and veteran populations: Initial assessment. Washington,
DC: The National Academies Press.
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“Knowing is not enough; we must apply.
Willing is not enough; we must do.”
— Goethe
Advising the Nation. Improving Health.
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The National Academy of Sciences is a private, nonprofit, self-perpetuating society
of distinguished scholars engaged in scientific and engineering research, dedicated to
the furtherance of science and technology and to their use for the general welfare.
Upon the authority of the charter granted to it by the Congress in 1863, the Acad-
emy has a mandate that requires it to advise the federal government on scientific
and technical matters. Dr. Ralph J. Cicerone is president of the National Academy
of Sciences.
The National Academy of Engineering was established in 1964, under the charter
of the National Academy of Sciences, as a parallel organization of outstanding en-
gineers. It is autonomous in its administration and in the selection of its members,
sharing with the National Academy of Sciences the responsibility for advising the
federal government. The National Academy of Engineering also sponsors engineer-
ing programs aimed at meeting national needs, encourages education and research,
and recognizes the superior achievements of engineers. Dr. Charles M. Vest is presi-
dent of the National Academy of Engineering.
The Institute of Medicine was established in 1970 by the National Academy of
Sciences to secure the services of eminent members of appropriate professions in
the examination of policy matters pertaining to the health of the public. The Insti-
tute acts under the responsibility given to the National Academy of Sciences by its
congressional charter to be an adviser to the federal government and, upon its own
initiative, to identify issues of medical care, research, and education. Dr. Harvey V.
Fineberg is president of the Institute of Medicine.
The National Research Council was organized by the National Academy of Sci-
ences in 1916 to associate the broad community of science and technology with the
Academy’s purposes of furthering knowledge and advising the federal government.
Functioning in accordance with general policies determined by the Academy, the
Council has become the principal operating agency of both the National Academy
of Sciences and the National Academy of Engineering in providing services to
the government, the public, and the scientific and engineering communities. The
Council is administered jointly by both Academies and the Institute of Medicine.
Dr. Ralph J. Cicerone and Dr. Charles M. Vest are chair and vice chair, respectively,
of the National Research Council.
www.nationalacademies.org
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COMMITTEE ON THE ASSESSMENT OF ONGOING EFFORTS IN
THE TREATMENT OF POSTTRAUMATIC STRESS DISORDER
Sandro Galea (Chair), Professor and Chair of the Department of
Epidemiology, Mailman School of Public Health, Columbia
University, New York, NY
Kathryn Basham, Professor and Editor, Co-Director of the PhD Program,
College of Social Work, Smith College, Northampton, MA
Larry Culpepper, Professor and Chairman of the Department of Family
Medicine, Boston University School of Medicine; Chief of Family
Medicine, Boston Medical Center, MA
Jonathan Davidson, Emeritus Professor, Department of Psychiatry,
Duke University Medical Center, Durham, NC
Edna Foa, Professor, Department of Psychiatry; Director, Center for the
Treatment and Study of Anxiety, University of Pennsylvania School of
Medicine, Philadelphia
Kenneth Kizer, Director, Institute for Population Health Improvement;
Professor, School of Medicine and Nursing, University of
California, Davis
Karestan Koenen, Associate Professor, Department of Epidemiology,
Mailman School of Public Health, Columbia University,
New York, NY
Douglas Leslie, Professor, Department of Public Health Sciences and
Department of Psychiatry, Pennsylvania State University,
State College
Richard McCormick, Senior Scholar, Center for Health Care Research
and Policy, Case Western Reserve University, MetroHealth Medical
Center, Cleveland, OH
Mohammed Milad, Associate Professor, Department of Psychiatry,
Harvard Medical School; Director of Behavioral Neuroscience
Laboratory, Associate in Research Psychiatry, Massachussets General
Hospital, Boston
Elspeth Cameron Ritchie, Professor, Department of Psychiatry, Uniformed
Services University of the Health Sciences; Chief Clinical Officer,
Washington, DC, Department of Mental Health
Albert “Skip” Rizzo, Associate Director, Institute for Creative
Technologies; Research Professor, Department of Psychiatry and
School of Gerontology, University of Southern California,
Los Angeles
Barbara O. Rothbaum, Associate Vice Chair of Clinical Research,
Department of Psychiatry; Director, Trauma and Anxiety Recovery
Program, Emory University School of Medicine, Atlanta, GA
v
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Douglas Zatzick, Professor, University of Washington School of
Medicine; Associate Vice Chair for Health Services Research, Medical
Director of the Inpatient Consultation Liaison Service, University of
Washington Harborview Level I Trauma Center, Seattle
Consultant
Carol Tamminga, Professor, Chairman, University of Texas Southwestern
Medical Center, Dallas
Study Staff
Roberta Wedge, Study Director
Margot Iverson, Program Officer (through January 2012)
Anne Styka, Associate Program Officer
Rebecca Hebner, Senior Program Assistant (through March 2012)
Joi Washington, Senior Program Assistant (since April 2012)
Heidi Murray-Smith, Program Officer, Board on Environmental Studies
and Toxicology
Norman Grossblatt, Senior Editor
Frederick Erdtmann, Director, Board on the Health of Select Populations
vi
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Reviewers
T
his report has been reviewed in draft form by individuals chosen for
their diverse perspectives and technical expertise, in accordance with
procedures approved by the National Research Council’s Report
Review Committee. The purpose of this independent review is to provide
candid and critical comments that will assist the institution in making its
published report as sound as possible and to ensure that the report meets
institutional standards for objectivity, evidence, and responsiveness to the
study charge. The review comments and draft manuscript remain confiden-
tial to protect the integrity of the deliberative process. We wish to thank the
following individuals for their review of this report:
Christopher K. Cain, Nathan Kline Institute for Psychiatric Research
Joseph T. Coyle, Harvard Medical School
Johanna T. Dwyer, Tufts Medical Center
Mardi J. Horowitz, University of California, San Francisco
Israel Liberzon, University of Michigan
John Parrish, Massachusetts General Hospital
Alan Peterson, University of Texas Health Science Center at
San Antonio
Gale S. Pollock, Pollock Associates, LLC
William E. Schlenger, Abt Associates Inc.
Murray Stein, University of California, San Diego
Although the reviewers listed above have provided many constructive
comments and suggestions, they were not asked to endorse the conclusions
vii
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viii REVIEWERS
or recommendations, nor did they see the final draft of the report before
its release. The review of this report was overseen by Floyd E. Bloom, The
Scripps Research Institute, and Jacquelyn C. Campbell, The Johns Hopkins
University School of Nursing. Appointed by the National Research Council
and Institute of Medicine, they were responsible for making certain that
an independent examination of this report was carried out in accordance
with institutional procedures and that all review comments were carefully
considered. Responsibility for the final content of this report rests entirely
with the authoring committee and the institution.
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Contents
Preface xiii
Acronyms xv
Summary 1
1 Introduction 17
Committee’s Charge, 19
Committee’s Approach, 19
Organization of the Report, 23
References, 24
History, Diagnostic Criteria, and Epidemiology 25
2
History of PTSD, 24
Diagnostic Criteria for PTSD, 26
Epidemiology of PTSD in the General Population, 29
Epidemiology of PTSD in Military and Veteran Populations, 37
Summary, 49
References, 49
3 Neurobiology 59
Adaptive and Maladaptive Stress Responses, 60
Models for the Development of PTSD, 66
Factors That Influence the Development of PTSD, 72
ix
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x CONTENTS
Implications for PTSD Prevention, Diagnosis, and Treatment, 83
Biomarkers, 90
Summary, 91
References, 92
4 Programs and Services for PTSD in the Department of Defense and
the Department of Veterans Affairs 111
The Department of Defense Health Care System, 111
Mental Health Care in the Department of Defense, 114
Transitioning Between the Department of Defense and the
Department of Veterans Affairs Health Care Systems, 132
The Department of Veterans Affairs Health Care System, 134
Mental Health Care in the Department of Veterans Affairs, 138
Collaborative Efforts Between the Department of Defense and the
Department of Veterans Affairs, 151
Research in the Department of Defense and the Department of
Veterans Affairs, 153
Cost Considerations, 155
Summary, 157
References, 168
5 Prevention 165
Overview of PTSD Prevention, 165
Pretrauma Prevention Efforts, 167
Interventions for Trauma-Exposed People, 170
Prevention in the Department of Defense, 176
Prevention in the Department of Veterans Affairs, 185
Summary, 186
References, 187
6 Screening and Diagnosis 195
Screening, 195
Considerations Regarding Screening in the Department of
Defense and the Department of Veterans Affairs, 199
Screening in Primary Care, 204
Screening Tools, 209
Diagnosis, 217
Quality of Life, Disability, and Resilience Measures, 220
Summary, 221
References, 222
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xi
CONTENTS
7 Treatment 231
Psychosocial Treatments for Chronic PTSD, 233
Pharmacotherapy, 246
Combined Psychotherapy and Pharmacotherapy Approaches, 254
Integrative Collaborative Care, 254
Emerging Therapies for PTSD, 255
Guidelines for Treatment of PTSD, 264
Summary, 273
References, 274
8 Co-Occurring Psychiatric and Medical Conditions and
Psychosocial Complexities 293
Co-Occurring Psychiatric Conditions and PTSD, 294
Co-Occurring Medical Conditions and PTSD, 296
Co-Occurring Psychosocial Problems and PTSD, 309
Summary, 323
References, 324
9 Access to Care 339
Barriers to Care, 340
Barriers to Delivery of Evidence-Based Care, 349
Facilitators of Care for PTSD, 351
Summary, 356
References, 356
10 Findings and Recommendations 363
Analyze, 364
Implement, 367
Innovate, 370
Overcome, 372
Integrate, 374
Phase 2, 376
References, 377
Appendixes
A Committee Member Biographies 379
B Congressional Legislation 387
C Posttraumatic Stress Disorder Programs in the Department
of Defense 391
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Preface
P
osttraumatic stress disorder (PTSD) is one of the signature injuries of
the U.S. engagements in Iraq and Afghanistan. Of the more than 2.6
million active-duty, National Guard, and reserve service members who
have been deployed to Operation Enduring Freedom (OEF) in Afghanistan
since 2001 and Operation Iraqi Freedom (OIF) since 2003, an estimated
13–20% of them have or may develop PTSD. Managing PTSD in those
populations is a huge task for the Department of Defense (DoD) and the
Department of Veterans Affairs (VA). The DoD and the VA have responded
with substantial funding to foster research, develop programs, and initiate
services to combat PTSD. Both departments are making strides in identify-
ing and treating people who have PTSD, but there are many obstacles to
the achievement of effective and timely treatments, from identifying those at
risk for PTSD to using the best evidence-based treatments—psychotherapy,
pharmacotherapy, or some combination. Diagnostic procedures and treat-
ment options are not standardized with respect to who uses which approach
and when. There is a need to ensure that service members and veterans who
seek treatment receive it in a timely and thorough manner, and to make
treatments available to those who are in remote locations or for whom
access to treatment is difficult. Research is being conducted to identify the
physiologic bases of reactions to trauma and to identify biomarkers for
preventing and diagnosing PTSD, and for treating it.
The present two-phase Institute of Medicine (IOM) study is particularly
timely, given the recent conclusion of OIF and the expectation that OEF will
be winding down in the next few years. The charge given to this committee
represents a serious commitment of the DoD and the VA to address health
xiii
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xiv PREFACE
care issues surrounding service members and veterans who have PTSD. This
phase 1 report summarizes much of the literature on the burden of PTSD in
service members and veterans, including National Guard and reservists, and
explores the options available in the DoD and the VA for the prevention of,
diagnosis of, and treatment for PTSD. In the second phase of its work, the
committee will focus on the evaluation of data provided by the DoD and
the VA and will investigate cost considerations, new neurobiologic findings,
and the use of complementary and alternative treatments. Although the
committee did visit one congressionally mandated site for this report (Fort
Hood, Texas), in phase 2 it will undertake visits to at least two other Army
sites—Fort Bliss, Texas, and Fort Campbell, Tennessee—and it hopes to
visit other military bases and VA medical facilities to gain an appreciation
of real-world successes and problems related to the diagnosis of and treat-
ment for PTSD in these settings. The committee recognizes the burden that
PTSD poses for many service members, veterans, and their families, and the
pressing need to prevent it, diagnosis it, and treat for it in those who have
given so much for this country.
The committee gratefully acknowledges the many individuals and
groups who generously gave their time and expertise to share their insights
on particular aspects of PTSD, who provided reports and data, and who
answered queries about their work and experience in dealing, personally
and professionally, with PTSD. Among the many people who helped the
committee are staff of the DoD and the VA, researchers, staff of veteran and
service member organizations, and members of the public who attended
the committee’s open meetings. The committee also visited U.S. Army Gar-
rison Fort Hood in Killeen, Texas, and expresses its appreciation for the
time, insights, and personal stories offered by a variety of base staff, mental
health providers, and service members who have PTSD and their families.
The committee is also grateful to Roberta Wedge, who served as study
director for this project, and to the IOM staff members who contributed
to this project: Rebecca Hebner, Margot Iverson, Heidi Murray-Smith,
Anne Styka, and Joi Washington. A thank you is also extended to William
McLeod, who conducted database and literature searches.
Sandro Galea, Chair
Committee on the Assessment of Ongoing Efforts in the Treatment of
Posttraumatic Stress Disorder
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Acronyms
ACT acceptance and commitment therapy
AFQT Armed Forces Qualification Test
APA American Psychiatric Association
ASD acute stress disorder
BDNF brain-derived neurotrophic factor
BHOP Behavioral Health Optimization Program
BICEPS brevity, immediacy, centrality or contract,
expectancy, proximity, and simplicity
CAM complementary and alternative medicine
CAPS Clinician-Administered PTSD Scale
CBCT cognitive-behavioral conjoint therapy
CBT cognitive behavioral therapy
CBT-MVA cognitive behavioral therapy–motor vehicle accident
CI confidence interval
CIDI Composite International Diagnostic Interview
CISD critical incident stress debriefing
COSC combat and operational stress control
COSR combat and operational stress reaction
CPT cognitive processing therapy
CRT cognitive rehabilitation therapy
CSC combat stress control
CSF Comprehensive Soldier Fitness
CT cognitive therapy
xv
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xvi ACRONYMS
CWT compensated work therapy
DART deployment anxiety reduction training
DCoE Defense Centers of Excellence for Psychological
Health and Traumatic Brain Injury
DCS d-cycloserine
DIS-IV Diagnostic Interview Schedule
DNA deoxyribonucleic acid
DoD Department of Defense
DSM-IV Diagnostic and Statistical Manual of Mental
Disorders–Fourth Edition
EFT emotional freedom technique
EMDR eye movement and desensitization reprocessing
FOCUS Families OverComing Under Stress
FORT functional and occupational rehabilitation treatment
FY fiscal year
GABA gamma-aminobutyric acid
GAF global assessment of function
GAO Government Accountability Office
GAT global assessment tool
HBOT hyperbaric oxygen therapy
HOPE Helping to Overcome PTSD with Empowerment
HPA hypothalamic-pituitary-adrenal
HT hydroxytryptamine
IED improvised explosive device
IOM Institute of Medicine
IPAP International Psychopharmacology Algorithm Project
IPT interpersonal therapy
IPV intimate partner violence
IQ intelligence quotient
IRT imagery rehearsal therapy
ISTSS International Society for Traumatic Stress Studies
MANSA Manchester Short Assessment of Quality of Life
MAO monoamine oxidase
MAOI monoamine oxidase inhibitor
MHAT Mental Health Advisory Team
MHS military health system
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xvii
ACRONYMS
MINI Mini-International Neuropsychiatric Interview
MRI magnetic resonance imaging
MST military sexual trauma
mTBI mild traumatic brain injury
MTF military treatment facility
NCS National Comorbidity Study
NCS-R National Comorbidity Study-Replication
NHMRC National Health and Medical Research Council
NICE National Institute for Health and Clinical Excellence
NIH National Institutes of Health
NIMH National Institute of Mental Health
NMDA n-methyl-d-aspartate
NVVRS National Vietnam Veterans Readjustment Study
OEF Operation Enduring Freedom
OIF Operation Iraqi Freedom
OMHO Office of Mental Health Operations (VA)
OND Operation New Dawn
OR odds ratio
OSCAR operational stress control and readiness
PCL PTSD Checklist
PC-PTSD Primary Care PTSD screen
PDHA Post-Deployment Health Assessment
PDHRA Post-Deployment Health Reassessment
PE prolonged exposure
PHA Periodic Health Assessment
PSS-I PTSD Symptom Scale—Interview Version
PTSD posttraummatic stress disorder
RAS reticular activating system
RCT randomized controlled trial
REACH Reaching Out to Educate and Assist Caring, Healthy
Families
REM rapid eye movement
RESPECT-Mil Re-Engineering Systems for Primary Care Treatment
of Depression and PTSD in the Military
RNA ribonucleic acid
rTMS repetitive transcranial magnetic stimulation
SCCIP-ND Surviving Cancer Completely Intervention Program–
Newly Diagnosed
SIP Structured Interview for PTSD
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xviii ACRONYMS
SIT stress inoculation training
SKY Sudarshan Kriya yoga
SNRI serotonin norepinephrine reuptake inhibitor
SPRINT Short Post-Traumatic Stress Disorder Rating
Interview
SRI serotonin reuptake inhibitor
SSRI selective serotonin reuptake inhibitor
STAIR Skills Training in Affect and Interpersonal Regulation
STRONG STAR South Texas Research Organizational Network
Guiding Studies on Trauma and Resilience
TBI traumatic brain injury
TMH telemental health
USUHS Uniformed Services University of the Health Sciences
VA Department of Veterans Affairs
VBA Veterans Benefit Administration
VHA Veterans Health Administration
VISN Veterans Integrated Service Network
VR virtual reality
VRE virtual reality exposure therapy
WHOQOL-100 World Health Organization Quality of Life
Assessment
WL wait list
